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The real causes of the worst drug crisis in US history

An addiction expert explains the root causes of the opioid epidemic.

“Superficial” is how Anna Lembke describes the common understanding of the opioid painkiller and heroin epidemic.

Lembke, a Stanford psychiatrist focused on addiction care, agrees that the commonly cited causes of the epidemic — doctors hoping to treat previously untreated pain conditions, pain patients demanding better treatments, and big pharma pushing opioids on the market — contributed to the vast overprescription of opioids. That let the pills flow not just to patients’ hands but to their family, their friends, and the black market.

But she argues that the crisis, which amounts to the worst drug epidemic in US history in terms of overdose deaths, goes far deeper.

“You can’t use the pills to extend your limits. You have to accept that there’s some things you just won’t be able to do anymore,” Lembke recently told me. “People are very resistant to that idea. I think that speaks to some of the core hope for at least Americans that they should really be able to keep doing what they were doing in their 20s, and that somehow a doctor should be able to fix them and make that happen, instead of accepting that maybe that’s something that they just can’t do anymore.”

She doesn’t deny that some people do suffer from horrible, crippling chronic pain. But she points out that the empirical evidence shows that opioids actually aren’t effective for chronic pain, and instead pose many risks in the long term, from addiction to overdose to a higher risk of injury to even increased levels of pain. So doctors, Lembke argues, need to find other solutions, like physical therapy, that may benefit patients.

And if that doesn’t work, then maybe a patient just needs to be taught how to cope with the pain, much like patients with other chronic illnesses are helped with figuring out how to live with their conditions.

“What I think is really important to remind people is that if opioids worked long-term, I would have no problem with patients taking them,” she said. “The fundamental issue is that they stop working and then you have an additional problem.”

Lembke has written and spoken a lot about these kinds of issues, most recently in her 2016 book Drug Dealer, MD. So I reached out to her to talk about the opioid epidemic and what we get wrong about addiction in America. What follows is our conversation, edited for length and clarity.

German Lopez

What are the roots of the opioid epidemic, as you see them?

Anna Lembke

What you’ll read about in the media is a good superficial summary of this problem. Basically, the epidemic began with doctors prescribing opioids more liberally for patients with pain — in part because we have an increasing number of people with pain in this country, and we were trying to address an unmet medical need. That was combined with aggressive marketing on the part of big pharma and small subgroups of pill mill doctors taking the opportunity to make money despite harming their patients. Those three factors are what you’ll read about.

But I think that’s a very superficial take at the end of the day on what was really going on. If you look more closely, it’s just not pill mill doctors who are overprescribing — we did a piece in JAMA that shows all doctors are overprescribing pain pills.

And as far as big pharma goes, big pharma has always existed in some shape or form, pushing their pills. So why opioids and why now?

And as far as an increasing number of patients in pain, we don’t really have more patients in pain than a lot of other high-income countries who are not consuming opioids at the same rate we are. We come down to 4 percent or 5 percent of the world population but consume 80 to 90 percent of the world’s opioids. So there’s something different about the United States, which I think warrants further examination.

German Lopez

So what do you think are the deeper roots here?

Anna Lembke

At the end of the day, opioids were the solution not for patients’ problems but for doctors’ problems.

There has been a huge transformation in the past 30 years in health care delivery, beginning with a migration out of private practice into large integrated health care centers. That’s something that I call the Toyotazation of medicine — tremendous pressure on doctors within these large integrated health care centers to practice medicine in a certain way and get patients out in a timely fashion to be able to bill insurers at the highest possible level and to make sure that their patients were satisfied customers.

This was a huge contributing factor to the opioid epidemic — by giving doctors a way to just give a pill to patients to get them out the door, while also feeling like they were doing something to help patients, at least in the short term. Opioids became the proxy for a doctor-patient relationship.

The other underrecognized piece of this is what I call the medicalization of poverty. Opioids have become a proxy for a social safety net. So we have doctors routinely confronted with patients who not only have multiple medical problems — from diabetes to hypertension to asthma to cardiac disease — but also very significant psychological, social, and economic problems. Many of them are undereducated. Many of them are underemployed. Many of them are homeless. Many of them are struggling with multigenerational trauma.

Because we lack a social safety net to take care of these people, we are now medicalizing their problems, and telling doctors that they have to take care of their problems. Doctors are feeling incredibly overwhelmed in this space with this growing population of individuals with very complex biological and psychosocial problems. In the face of that, they’re prescribing opioids — because opioids work quickly, patients are grateful, and it seems to be something they can do in the face of overwhelming problems.

The other piece of it are new illness narratives that have now become commonplace. Everything from “pain is dangerous” to “people are fragile” to “the body can’t heal itself” and “doctors have superhuman abilities to heal” and “illness is an identity” and “victimhood gives you a right to be compensated.” These are illness narratives that I think create a culture in our society, which we’re not even aware of, that’s contributed to the opioid epidemic.

German Lopez

One thing you suggested is that these opioids will provide relief for someone even if they don’t have pain. That’s why people will use them recreationally.

So if I’m understanding you correctly, the argument is that doctors, faced with these patients with all sorts of problems, are like, “Well, I don’t know how to deal with a lot of this, so maybe I will prescribe an opioid because that’ll give them at least some sense of relief.” And maybe the patient will even say that he has pain and the doctor will interpret it to be something that an opioid can treat. Am I getting that right?

Anna Lembke

Yeah.

A doctor isn’t going to prescribe an opioid unless they can diagnose a condition to justify it, because they’re worried about their practice and their life, and they want to practice what’s considered the standard of care.

But what’s become the standard of care for prompting an opioid prescription is very little in the way of evidence for having any kind of bona fide medical condition. All you really have to do is show up [and] say you are in pain, even in the absence of any objective points of disease or pathology. And that alone is enough to warrant and justify a doctor’s prescription for an opioid — with little oversight or checking on whether that individual has that disease or may in fact be abusing or addicted to opioids.

German Lopez

The CDC [Centers for Disease Control and Prevention] has told doctors to be more careful with prescriptions, essentially creating a few more checks in the system before a doctor prescribes opioids. What else would you like to see done?

Anna Lembke

On a large scale, the solution is going to depend on closing the gap between mechanized, industrialized, computerized health care delivery and the growing psychological, economic, and spiritual needs of our patients. There’s a huge gap there that’s not being met. So we have to reform our health care system in order to meet the growing needs of our patients that really, on some level, are largely disconnected [from] whether they have a disease in the traditional sense.

Our increasingly industrialized health care system is very poorly suited to meeting those kinds of needs. So it’s really great when it comes to cataract surgery, knee replacement, or even if you have an ear infection or pneumonia and you need some antibiotics or something. We’re really horrible at managing long-term, chronic, and remitting illnesses, which is what the highest consumers of health care have. That’s everything from depression to chronic pain to addiction. We need to reform health care to help those people.

On the smaller scale, there are three things doctors can do. They can initiate opioids less often, and that’s what the CDC guidelines were all about. They said that doctors should not be giving patients more than about three days of opioids for an acute medical condition. They shouldn’t be using [them] for a chronic condition because they don’t work [for chronic pain]. And they have to decrease the number of new initiates.

That doesn’t solve the problem of the very large number of people who are already on prescription opioids and are now dependent. Some of them are probably never going to get off. So the second piece is that we have to train doctors to better monitor and more safely prescribe opioids for patients who need opioids. Some of the ways to do that are to check the prescription drug monitoring database, get urine drug screens, [and] talk to family members.

And when doctors identify that patients who are on opioids are being harmed more than they’re being helped, then doctors have to work with those patients to get them off opioids.

One of the secrets of medicine — secret even to doctors — is that you can’t just stop opioids or quickly go down and the [patient] will be fine. You can’t do that. They’ll go through terrible, excruciating withdrawal. And in my practice I now have what I call a deprescribing practice — most of my efforts are spent on helping patients get off medication that they’ve become dependent on or addicted to after it was prescribed by doctors for a legitimate medical condition. And typically my patients take years, so I can go down by a little bit every couple of months. That’s all they can tolerate.

I get tons of referrals because doctors generally have no idea how to do this work, and many of them don’t have the time or resources that are required.

German Lopez

You mentioned one thing in this broader conversation that just does not seem to be getting through to a lot of people: that the evidence does not show that opioids are effective for treating chronic pain. Given that, what do you tell patients who want to treat their chronic pain and think opioids are an option?

Anna Lembke

I say it’s absolutely true that if you were to get opioids for your pain, it would be like a magical cure for about a month or maybe two.

But after a while, there’s a very high likelihood that they would stop working. And then you would have two problems: You would have your pain, and you would be dependent on this drug and experience painful withdrawal if you try to get off [opioids].

Then I have to say to patients, “What are we left with if opioids are not a good option for you?” We’re left with trying to help you as much as possible with alternatives to treat your pain. It’s not going to be one thing; it’s going to be a multimodal combination of non-opioid medication — physical therapy, massage, acupuncture.

If you tried all of that and none of it worked, what we’re left with is learning to live with pain. How can we create a lifestyle that you’re comfortable with while knowing that you’re not going to be able to get rid of the pain? That becomes a spiritual, existential question for a lot of people — a very profound one that takes a lot of thoughts and efforts to have questions about. It’s not something you can do in five minutes.

German Lopez

So say somebody has been on opioids for two months. So now if they try to get off opioids, they’re going to have pain. It’s almost a mind game at that point, where they think the pain they’re feeling when they stop taking opioids is their chronic pain that they were treating coming back — when it’s really withdrawal and the pain that comes with that. It’s like the opioids trick them into thinking they’re treating this chronic pain when they’re actually creating another layer of problems that they didn’t have before.

Anna Lembke

That’s exactly right. And what you just did there is what I spend a lot of my time trying to tell patients about.

I have to tell them very specifically that as we go down on the opioid, they will experience worse pain, because full-body pain is part of opioid withdrawal — even in people who don’t have a pain condition. Since they have a pain condition, as they are withdrawing from opioids, the pain will be even worse for them. They will have pain in the place where they normally had pain, and they may even have pain in other parts of their body.

But then I have to say that the pain they feel is not the pain that they will end up having to live with. It is opioid withdrawal–mediated pain that over time, as their brain adjusts to the new lower dose, they’ll be back at their original pain level.

And then I say to them — and here’s the really hopeful possibility — since we know that chronic opioid use can in some cases make pain worse, there’s a possibility that when they’re all done with withdrawal and they haven’t had any opioids for, say, a month or two or six, their pain might actually be better than it has been in years. It may be better than it was for any of the time they were on opioids.

German Lopez

One common counterargument by pain patients I hear to all of this: When you tell people with live with pain, you would never say to a heart disease patient that they need to just tough it out and live with their problem. How would you respond to that?

Anna Lembke

Well, I don’t think that’s true. If you have a congestive heart failure, and because of that you have shortness of breath, that’s a chronic illness that a doctor can’t cure. So you need to modify your behavior. You can’t run down the street anymore, because you can’t get enough air. You may have to sleep with an oxygen tank at night, so you can sleep through the night.

Almost every single medical condition has a chronic form that’s incurable, and it just becomes an issue of palliation.

What I think is really important to remind people is that if opioids worked long-term, I would have no problem with patients taking them. The fundamental issue is that they stop working and then you have an additional problem.

German Lopez

That gets at why I’ve personally always been skeptical of that counterargument. If you have a disease and don’t have a cure for it, you wouldn’t just throw dangerous drugs at it in hopes that it would maybe help. You would find a way to work around it.

So a seriously ill cancer patient, you would try to find ways to make them comfortable and mitigate the symptoms. But you wouldn’t just throw potentially dangerous drugs at them.

Anna Lembke

Right.

So, for example, this is a clinical scenario that happens to me all the time: I have a patient that I’m prescribing an opioid. Then they come in and tell me that they ran out three days early. And I tell them, “You can’t do that. You have to take it as prescribed.” And they tell me, “Well, I was doing yard work, and I had to cut down all these trees, I was chopping wood, and my pain was horrible. So I had to take more.”

And then I have to find a way to say to the patient, that’s not okay. You can’t use the pill to compensate for what your body can’t do anymore.

If you take additional opioids, you can’t hear the signals from your body about what you shouldn’t be doing, and then maybe you’re going to do some long-term damage above what’s already been done.

But even more importantly, you can’t use the pills to extend your limits. You have to accept that there’s some things you just won’t be able to do anymore.

People are very resistant to that idea. I think that speaks to some of the core hope for at least Americans that they should really be able to keep doing what they were doing in their 20s, and that somehow a doctor should be able to fix them and make that happen, instead of accepting that maybe that’s something they just can’t do anymore.

German Lopez

I wanted to zoom out a bit to talk about patients who already are addicted. Based on your practice and talking to other doctors, what do you think are the big things that we get wrong in treating and dealing with addiction in America?

Anna Lembke

The biggest thing we get wrong is not embracing the idea of addiction as an illness. What I say to people is even if you don’t really believe that addiction is an illness, you as a doctor have to pretend like it is an illness. Because meanwhile, you’re treating all these other invisible conditions, from ADHD to chronic pain to depression. If you lump addiction in there too, you’re going to be contributing to the prescription drug problem.

So we have to totally embrace this idea that addiction is an illness. We have to put it on the problem list when we identify it. And instead of rejecting these patients or getting angry at them or kicking them out of our practice, we have to give them treatment for addiction.

There is treatment out there. It works just as well as the treatments for other chronic illnesses, from asthma to diabetes Type 2 to various forms of heart disease. The data shows this fundamentally: that there’s about a 50 percent response rate for treatment for addiction, which is on par with response rates for other chronic medical conditions. There are similar rates for remission and relapse for treatment.

Once we do that, I think not only patients will be better off but doctors will be happier, because they will actually have the toolbox to address these problems when they arise.

What’s happening now is that doctors are not educated in how to intervene when substance abuse problems come up. So they feel incompetent. When these issues come up, they’d rather not know, because they don’t know what to do about them when they find them. But if doctors were really educated in this arena, then at least we’d refer [patients] to someone else who can treat it.

The other main thing we get wrong is the enormous stigma against opioid agonist therapy [such as methadone and buprenorphine] for opioid addiction. People are just fundamentally repelled by using opioids to treat opioid addiction. I can certainly relate to the paradox and being uncomfortable with it. But the data at this point is just overwhelming that somebody with severe opioid addiction, if you get them on opioid agonist therapy, their lives are vastly better.

German Lopez

Some people are still skeptical of the idea of treating addiction as a disease. How do you persuade someone that it is a disease, not a moral failure or anything else they might think it is?

Anna Lembke

Well, again, I start by saying, “I don’t care if you believe or not. Pretend like you do, because otherwise you’re a part of the problem.”

But all you have to do is, in your family or in your clinical work, if you see somebody who continues to use despite their lives being totally destroyed — losing their jobs, losing loved ones, ending up in jail — nobody would choose that. Nobody anywhere would ever choose that life. So clearly it is beyond this individual’s control on some level.

I’ve seen this concept clinically that people who are addicted are in denial. No, they’re not. A lot of them know they’re addicted, and they still can’t stop. And they want help.

I think what can really help — and this has been shown to help — is personal stories of addiction. When doctors really see that, it makes a huge difference in opening their eyes to the reality of addiction in its severe form really being a disease.